Obesity is a national health concern, and mental health professionals are frequently involved in attempts at treatment. However, the potential impact of significant personality disturbance on obesity treatment has rarely been considered in the published literature. This article reviews possible links between obesity and borderline personality disorder and discusses treatment approaches for those individuals demonstrating such comorbidity. Approaches include modification of current techniques for obesity treatment and incorporation of psychodynamic counseling specific to borderline personality disorder.

Obesity has become a national health concern. Nearly one third of the U.S. population is obese, including up to one half of all adult African-American and Hispanic women (Kuczmarski, Flegal, Campbell, & Johnson, 1994; Rand & Kuldau, 1990; Wing, 1993). The potential medical complications attributable to, or complicated by, obesity include hypertension, diabetes, and cardiovascular disease. Obesity-related illnesses cost more than $45 billion annually in the United States (Wolf & Colditz, 1996). Despite apparent health risks, available studies indicate that obese women are actually less likely to seek health care (Olsen, Schumaker, & Yawn, 1994) and may change physicians more readily (Sansone, Sansone, & Wiederman, 1998) leading to less continuity of care.

In addition to health consequences, the social costs of obesity include negative attitudes from health care professionals (Blumberg & Mellis, 1985; Young & Powell, 1985), social stigmatization and discrimination (Allon, 1982; Jackson, 1992), and economic poverty and decreased opportunity for intimate relationships (Gortmaker, Must, Perrin, Sobal, & Dietz, 1993; Sobal & Stunkard, 1989; Wiederman & Hurst, 1998). Given the medical, economic, and social consequences of obesity, it is not surprising that mental health professionals are often called upon to assist in weight reduction attempts among obese individuals (Blechman & Brownell, 1998; Melcher & Bostwick, 1998). Yet, to treat obesity, etiology must be considered.

This article explores the relationship between borderline personality disorder and obesity treatment. The authors discuss treatment approaches for those individuals demonstrating such comorbidity, describing modifications of traditional interventions for obesity as well as the integration of a psychodynamic counseling approach.

BPD is currently conceptualized as an early developmental trauma syndrome, which is mediated by the individual's temperament as well as triggering events (Zanarini & Frankenburg, 1997). Repetitive trauma in early development (e.g., sexual abuse, emotional and/or physical abuse or neglect) may lead to the consolidation of BPD among some individuals. (Note that trauma is a nonspecific, but contributory, factor in many types of psychopathology including borderline personality). BPD, in turn, is associated with self-regulation deficits (American Psychiatric Association, 1994) that may manifest in a variety of ways (e.g., illicit and prescription drug abuse, alcohol abuse, money-management difficulties) including disordered eating (e.g., bulimia nervosa, binge-eating disorder). With regard to obesity, it is conceivable that long-standing difficulties with oral self-regulation could result in chronic overeating among some individuals, which would eventually result in progressive weight gain over a period of time (Sansone, Sansone, & Wiederman, 1997).

To date, most studies of personality disorder among obese research participants have concluded that a significant minority (1% to 30%) has BPD (for review, see Sansone et al., 1997). Despite appropriate: criticism because of small samples and narrow sample selection (e.g., gastric surgery patients, patients in weight-loss programs), research indicating that BPD may be more frequent among those seeking psychological treatment (Sansone, Sansone, & Morris, 1996), and limitations with regard to the measurement of personality disorder diagnosis, most available data indicate a substantially greater prevalence of BPD among the obese than the 2% prevalence in the general population (American Psychiatric Association, 1994). Whether BPD is a genuine causal factor for obesity remains to be empirically determined. We are not aware of any studies examining the prevalence of obesity among individuals with BPD.

From a clinical perspective, the dynamics of an underlying personality disorder would appear to temper the treatment approach to weight disorder, as is the case among individuals with other types of eating disorders (Dennis & Sansone, 1997). In those individuals with BPI), we believe, based upon our clinical experience, that the prevailing interventions in the management of obesity (i.e., weight disorder) should: (1) be slightly modified to accommodate the dynamics of BPD and (2) incorporate a psychodynamic treatment approach. These collective interventions appear to provide external as well as internal stabilization of these individuals--combined processes that promote self-regulation. Although empirically untested, the following recommendations appear clinically plausible.

Behavior Modification

Behavior modification for the treatment of obesity has a long history and entails a variety of concepts designed to address food purchasing, consumption, and storage as well as reducing food as a stimulus (Gladis et al., 1998; Willard, 1991; Wing, 1992). Specific examples of techniques include self-monitoring of dietary intake, eating at home and only in locations designated for eating, minimizing food cues in the home (e.g., decrease visibility of food), repackaging bulk foods into portions or specified units, and limiting food presence to the kitchen or pantry. Most behavioral interventions include some form of cognitive restructuring (Brownell & Foreyt, 1986), and studies indicate that this type of treatment can result in weight reduction for at least some individuals (Baker & Kirschenbaum, 1993; Foreyt & Goodrick, 1994a; Gladis et al., 1998).

For individuals with BPD, behavior modification for the treatment of obesity would probably undergo little alteration in content. However, repetitive review and reinforcement of techniques by the counselor is likely to be most effective for these individuals, a process that establishes and consolidates an ever-present external treatment structure. A repetitive structured approach is likely to facilitate incorporation of principles into the individual's behavioral repertoire.

Exercise Programs

Studies indicate that exercise is an important facet of treatment for obese individuals (Foreyt & Goodrick, 1994b, 1994c; Grilo, 1995). Because the psychodynamics of borderline personality include the tendency to perceive in absolutes (i.e., split perceptual style), these individuals may either overly embrace or immediately reject exercise as an intervention. If exercise regimens are embraced, clients with BPD may harbor an extremely unrealistic approach (e.g., buying expensive workout equipment, committing to aerobics for several hours per day, signing up for costly memberships to health clubs). At the other extreme, these individuals may strongly resist any impetus to exercise, legitimately explaining that such activities are embarrassing, impractical, or physically uncomfortable.

The treatment modification for this intervention is to reframe the exercise concept in terms of "self-regulation," which means learning to modulate extremes or to achieve overall balance. Exercise excess or avoidance becomes the focus of therapeutic work. Helping the client to modulate exercise activities may entail confirming realistic exercise schedules, defining acceptable forms of exercise, extensive contracting, support, and confrontation by the mental health counselor as well as psychodynamic intervention (see below) around the issues of self-regulation and splitting (i.e., perceiving in absolutes).

Surgical Intervention

Since the 1950's, various surgical approaches to the management of obesity have been undertaken, but still remain dramatic and controversial. Surgical intervention for obesity is a high-risk undertaking, not only because the surgery poses a medical risk (Ernsberger, 1987), but longterm benefits among patients may be limited (Wolfel, Gunther, Rumenapf, Koerfgen, & Husemann, 1994). Our clinical experience indicates that some clients with BPD may sabotage the surgical procedure by impulsively eating amounts of food that are too excessive for the newly devised gastric reservoir to process. It appears that BPD may be a relative contraindication for the surgical treatment of obesity, given the preceding risks and potentially limited benefits.

Unnatural Dietary Approaches

A fundamental principle in obesity treatment has been the reduction of caloric intake (Foster & Kendall, 1994; Gast & Hawks, 1998). This observation has occasionally culminated in very restrictive menu plans that are described as low-calorie diets (LCDs) or very low-calorie diets (VLCDs), usually less than 500 calories per day. Low-calorie diets may consist of unnatural foods (e.g., liquid supplements) as well as have poor nutritional balance.

These very structured, extremist dietary approaches may be appealing to individuals with BPD in that they eliminate the need for integrative functions (i.e., the need to modulate or regulate). That is, the menu plan consists of absolutes (i.e., "good" foods and "bad" foods), and the only task is to have sufficient stamina and resilience to tolerate these programs. Although these diets may be attractive, participants appear to experience a multitude of program failures (Wooley & Garner, 1991). In addition, these cycles of engagement and failure may culminate in "yoyo" dieting or weight cycling.

Among individuals with BPD, intervention centers on reframing the treatment goal as the normalization of eating patterns, rather than weight loss per se. We typically recommend 1,800-2,200 calories per day, distributed in four feedings (breakfast, lunch, dinner, evening snack). Additionally, we suggest consultation with a dietitian to construct an individuallly designed exchange menu plan based on the client's genuine food preferences. Many individuals elect only four or five breakfast and lunch plans, retaining more flexibility for dinner and the evening snack. Foods that trigger binge eating in some individuals may need to be initially restricted, but these foods might be re-integrated into the menu plan, if possible, with strategies for guaranteeing portion size (i.e., practice with food models, cognitive strategies). Weight assessment is infrequent, usually no more often than once per month, because weight loss is not the goal of treatment. Rather than a temporary "diet," this "menu plan" is lifelong and emphasizes normalized eating patterns.

With the normalization of eating patterns, weight loss is likely to occur in most individuals (Gast & Hawks, 1998; Tanco, Linden, & Earle, 1998). On rare occasion, some individuals may lose excessive amounts of body weight (greater than 10% to 15% per year), which heightens the physiologic effects of a caloric deficit state (i.e., starvation). In these cases, daily calorie levels may be increased to counter the effects of starvation and accommodate no more than 10% to 15% weight loss per year (Fairburn & Cooper, 1996). Weight plateaus are reframed as periods of homeostasis. The "slowness" of the weight-loss process is reframed to emphasize that gradual changes in diet and exercise are associated with better outcomes (Foreyt & Goodrick, 1994c). Again, it is important to emphasize that the treatment goal is the normalization of eating patterns, not weight loss per se.

On rare occasion, some obese individuals may not lose weight despite earnest attempts to normalize eating patterns (Melcher & Bostwick, 1998). These individuals (i.e., those who struggle to lose weight even at normal calorie levels) may be metabolically suppressed or may be genetically predisposed to obesity (i.e., average calorie levels precipitate weight gain).

Pharmacologic Intervention

Most of the recent focus on obesity treatment has been on neurochemical factors and pharmacologic intervention (Campfield, Smith, & Burn, 1998; Lucki, 1998). To date, appetite suppressants have been consistently associated with medical (e.g., hypertension, valvulopathy) and/or psychiatric (e.g., depression, agitation, addiction) concerns. Research studies with appetite suppressants have been of limited duration (generally less than one year) and suggest the development of tolerance over time (National Task Force on the Prevention and Treatment of Obesity, 1996; Rowland, 1994). They do not enable endless weight loss and their use appears to result in eventual weight plateaus. The use of appetite suppressants is not allowed in most states for longer than a year, and at the termination of their use, body weight often increases with the re-emergence of chaotic eating. However, researchers are continuing to explore pharmacologic alternatives for the management of obesity.

Given the psychodynamics of BPD, some individuals may perceive that medication is "the answer" (i.e., a convenient means of controlling oneself), justifying the abandonment of other adjunctive approaches such as behavior modification, exercise, and counseling. In addition, because individuals with BPD have long-standing difficulties with self-regulation, some may be at risk for medication misuse or abuse. Finally, in an unfortunate way, these drugs may tend to further distance clients with BPD from the inevitable task of self-regulation.

For most individuals with BPD, the counselor should carefully evaluate with the client the preceding risks of appetite suppressants. Greater support of appetite suppressants might be possible if and when safer and more effective medications are available.

Additional Treatment Recommendations

Among the obese with BPD, most time-limited interventions are problematic; these individuals cannot be expected to reasonably improve self-regulation skills in a brief period of time. In addition, ongoing therapeutic support is essential (i.e., the counselor should anticipate lengthy treatment).

The avoidance of defined weight goals or target weights is suggested. The fundamental treatment goal is the normalization of eating patterns, and hopefully, with subsequent self-regulation, body weight will decrease. Still, the mental health counselor must actively and sensitively confront the unlikelihood of attaining an ideal body weight (Foster, Wadden, Vogt, & Brewer, 1997). At times, relinquishing this quest relieves the pressure that some individuals place upon themselves, enabling the treatment to progress more effectively. Despite emphasis on the fact that even small decreases in body weight have meaningful health benefits, accepting the loss of "body ideal" can be an overwhelming and painful process (Wilson, 1996).

Finally, at the present time, there are no nationally recognized support groups for individuals who are obese and have BPD. Many such clients find that Overeaters Anonymous falls short of their extensive psychological needs (Westphal & Smith, 1996). Ideally, a group model would enable ongoing peer support and would compliment the modified treatments for obesity that we have described.

Psychodynamic Counseling

A few writers have considered obesity treatment from a psychodynamic perspective (Clerici, Basile, Pisoni, Amatulli, & Cazzullo, 1990; Leach, 1998). In conjunction with the preceding techniques and their modifications for individuals with borderline personality, the use of psychodynamic counseling is, in our opinion, a fundamental intervention for these individuals. Psychodynamic intervention not only augments the previously noted strategies, but assists clients in understanding their issues around poor self-regulation.

We have described our psychodynamic treatment approach to BPD elsewhere (Dennis & Sansone, 1989, 1990, 1997; Sansone & Johnson, 1995). Our approach consists of four stages of treatment. The first is the creation of a stable treatment environment (e.g., longitudinally available counselor, standing appointments, stable office site, client resources for a longitudinal treatment). The second stage is the consolidation of a therapeutic working relationship (e.g., extensive relationship-building techniques, promotion of reality, staying in the "here and now," counselor monitoring of boundaries, interpretation of emerging transferences, limit setting that is supportive yet firm).

The third stage of psychodynamic treatment focuses on self-regulation. During this phase of the treatment, the underlying dynamics of the individual are explored and processed, particularly those dynamics that legitimize the erosion of self-regulation. Examples of these dynamics include the need to: (1) punish oneself through self-sabotage ("I don't deserve to be a normal weight"); (2) reinforce an ongoing negative self-identity through repetitive self-defeating behavior; (3) regulate emotions (i.e., self-soothe or control anxiety through binge eating); (4) organize a fragmenting self (i.e., contain a quasi-psychotic episode); (5) elicit responses from others (i.e., socially provoke); (6) displace feelings of anger to de-regulation (i.e., over-eating); and (7) develop and maintain a social handicap.

Mental health counselors need to be aware that clients with BPD may have a high rate of prior sexual abuse (recall the role of early developmental trauma in the consolidation of BPD; Hurlbert, Apt, & White, 1992; Zanarini et al., 1997). Sexual abuse is related to an increased incidence of subsequent sexual dysfunction (Golding, 1996; Wyatt, 1991) as well as a greater risk of subsequent sexual victimization (Beitchman et al., 1992; Messman & Long, 1996). In this regard, obesity may facilitate the avoidance of sexual attention or demands from a partner or potential partners. It may also prevent some individuals with traumatic histories from having to address problematic interpersonal areas (Clerici et al., 1990).

A prior history of sexual abuse has been reported to impede the treatment of obesity. Weiner and Stephens (1996) noted that, among many women who experience compulsive eating, there is a weight barrier, or certain body weight (frequently lower than the individual's current weight) that precipitates extreme anxiety. These "barrier weights" may coincide with the body weight at which the individual woman experienced a sexually traumatic event or the onset of sexual abuse (i.e., the maintenance of a relatively higher body weight after sexual abuse or trauma may serve a self-protective function).

Although some studies have revealed general improvement in sexual functioning after weight loss, others have indicated substantial distress related to sexuality following weight loss (Stuart & Jacobson, 1987). Sexual distress with weight loss may be more likely among individuals with a history of sexual abuse, particularly among those with comorbid BPD. This may explain the apparently surprising finding that sexually abused obese individuals enrolled in a hospital-based weight management program were less successful at weight loss relative to a matched sample of nonabused peers (King, Clark, & Pera, 1996). These issues may not be apparent at the outset of treatment but may emerge as weight is lost, the individual becomes more physically attractive to others, or the balance of power in a current relationship with a partner is disrupted (Stuart & Jacobson, 1987). A psychodynamic approach can be useful in exploring and confronting these issues.

During the fourth stage of treatment for BPD, the focus is closure or termination. This phase of treatment may last for several months or longer and is fraught with stress for the client. Regression is frequent and usually highlighted by behavioral deregulation (Sansone, Fine, & Dennis, 1991).

Again, we wish to emphasize the importance of slightly modifying current weight-disorder techniques for this unique population and augmenting obesity treatment with a psychodynamic approach for BPD. This combination of interventions has not been empirically tested and is not described in the general treatment recommendations for obese individuals, with or without BPD.

Obesity is clearly a national health concern. A variety of interventions are recommended, but we are not aware of any previous literature addressing the modifications of these interventions and/or augmentation of treatment with psychodynamic counseling among obese, individuals with BPD. The proposed treatment approach, while probably helpful for many individuals, is particularly suggested for those obese clients with BPD. Unfortunately, we are not aware of any outcome studies with this unique clinical population. One of the challenges for the future will be exploration of treatment outcome as well as the development of longitudinal support groups for these clients.

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